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PACES 2024 > Station 1: Respiratory > Flashcards

Station 1: Respiratory Flashcards

1
Q

key presentation points in respiratory examination

A
  1. respiratory distress
  2. cyanosis
  3. clubbing
  4. trachea/ apex
  5. pulmonary hypertension/ cor pulmonale
  6. rheumatological findings
  7. LN
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2
Q
A
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3
Q

what are the surface markings of the right lung anteriorly?

A

4th rib and above = upper lobe on the right
4th to 6th rib = middle lobe on the right

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4
Q

what are the surface markings of the left lung anteriorly?

A

6th rib and below on the left = left lower lobe

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5
Q
A

Asymmetrical chest wall with absent ribs
+ Lateral throacotomy scar

–> Thoracoplasty: possibly for TB treatment in the past

can get complications of respiratory failure, and BIPAP may be useful

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6
Q

lateral thoractomy scar with normal underlying lung on examination?

A

lung transplant
pleurectomy (e.g. for recurrent pneumothorax in Ehlers Danlos)
Bullectomy

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7
Q

lateral thoractomy scar with abnormal underlying lung?

A
  • reduced breath sounds:
    lobectomy
    pneumonectomy (no breath sounds)
  • COPD with lung volume reduction surgery
  • Lung transplant with complications
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8
Q

differential diagnoses for a patient with clubbing and crepitations?

A

bronchiectasis
pulmonary fibrosis
mitotic lung lesion (cancer)
abscess

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9
Q

what is bronchiectasis?

A

irreversible bronchial dilatation and bronchial wall thickening, secondary to repeated infection and chronic inflammation

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10
Q

clinical course of bronchiectasis?

A

chronic, progressive with recurrent infective exacerbations

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11
Q

symptoms of bronchiectasis?

A

productive purulent cough
dyspnoea
haemoptysis

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12
Q

signs of bronchiectasis?

A

coarse late inspiratory (and expiratory) crepitations
+/- expiratory wheeze
clubbing may be present

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13
Q

what is bronchiectasis sicca?

A

“dry” bronchiectasis
presents with recurrent haemoptysis and dry cough

affects the upper lobes therefore good drainage

usually from past history of granulomatous infection eg TB

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14
Q

what are the causes of focal bronchiectasis?

A

luminal blockage: foreign body, broncholith (focal calcified endobronchial material which usually follows erosion by a granulomatous peribronchial lymph node (e.g. TB))

arising from the wall: malignancy

extrinsic: enlarged LNs especially middle lobe from TB/fungi, displacement of airways post lobar resection

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15
Q

causes of diffuse bronchiectasis?

A

post-infectious:
- bacteria: pseudomonas, haemophilus, pertussis
- TB
- aspergillus: allergic bronchopulmonary aspergillosis
- virus: adenovirus, measles, influenza

congenital:
- cystic fibrosis
- alpha 1 antitrypsin deficiency
- kartagener’s syndrome of immotile cilia
- hypogammaglobulinaemia (primary immunodeficiency)

rheumatological:
- rheumatoid arthritis
- SLE
- sjogrens

others:
yellow nail syndrome
young’s syndrome
idiopathic (50%)
inflammatory bowel disease (UC, crohn’s)
congenital kyphoscoliosis

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16
Q

post infectious causes of diffuse bronchiectasis?

A
  • bacteria: pseudomonas, haemophilus, pertussis
  • TB
  • aspergillus: allergic bronchopulmonary aspergillosis
  • virus: adenovirus, measles, influenza
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17
Q

congenital conditions that may lead to diffuse bronchiectasis?

A
  • cystic fibrosis
  • alpha 1 antitrypsin deficiency
  • kartagener’s syndrome of immotile cilia
  • hypogammaglobulinaemia (primary immunodeficiency)
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18
Q

rheumatological conditions causing diffuse bronchiectasis?

A
  • rheumatoid arthritis
  • SLE
  • sjogrens
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19
Q

other causes of diffuse bronchiectasis? (not 2’ infection/congenital/ rheumatological)

A

yellow nail syndrome (yellow nails, bronchiectasis, pleural effusion and lymphoedema)
young’s syndrome (bronchiectasis, rhinosinusitis, infertility due to obstructive azoospermia)
idiopathic (50%)
inflammatory bowel disease (UC, crohn’s)
congenital kyphoscoliosis

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20
Q

what is kartagener’s syndrome?

A
  • a type of immotile ciliary syndrome -> retained secretions, recurrent infections and thus, bronchiectasis

comprises of:
- dextrocardia, situs inversus
- bronchiectasis, sinusitis, frontal sinus dysplasia, otitis media
- infertility

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21
Q

what is cystic fibrosis?

A

most commonly due to mutations to CFTR (CF transmembrane conductance regulator)

recurrent respiratory infections with pancreatic exocrine deficiency and short stature
- usually affects upper lobes

dx: sweat test: elevated sweat sodium and Cl concentrations, genetic testing

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22
Q

what kind of sputum in bronchiectasis?

A

3 layered sputum:
foamy upper layer,
mucous middle layer,
viscous purulent bottom layer

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23
Q

what are the differences between bronchiectasis vs COPD?

A

they may occur concomitantly

cause: cigarette smoke (COPD) vs infection/ genetics (bronchiectasis)

infection: usually secondary (COPD), primary (Bronchiectasis)

organisms: Strep pneumo, haemophilus (COPD) vs Haemophilus, pseudomonas (Bronchiectasis)

symptoms: dyspnoea, chronic cough (COPD) vs dyspnoea, productive cough, haemoptysis (bronchiectasis)

sputum: mucoid clear (COPD) vs 3 layered, purulent (bronchiectasis)

CXR: hyperlucency, hyperinflated (COPD), airway thickening, dilated airways (bronchiectasis)

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24
Q

what are the complications of bronchiectasis?

A
  • pneumonia, collapse, pleural effusion, lung abscess, pneumothorax, haemoptysis
  • brain asbcess
  • sinusitis
  • amyloidosis
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25
Q

ix of bronchiectasis?

A

to diagnose:
HRCT

CXR: helpful for diagnosis, extent and to assess for complications

Lung function tests: obstructive pattern

assess for complications:
FBC CRP
Sputum studies

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26
Q

CXR findings of bronchiectasis?

A

diagnosis:
- dilatated and thickened airways
- signet ring sign
- tram lines

extent and distribution

complications: pneumonia, abscess, pleural effusion

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27
Q

lung function tests in bronchiectasis?

A
  • obstructive pattern with FEV1/FVC < 70%
  • severity of obstruction based on FEV1
  • some reversibility with beta agonist: 40% of patients have >15% improvement
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28
Q

HRCT findings in bronchiectasis?

A

diagnostic:
- dilation of airway lumen > 1.5x compared to nearby vessel
- signet ring sign (dilated bronchus with its pulmonary artery)
- lack of tapering of any airway toward the periphery with presence of bronchi within 1cm from the pleura
- Reid’s classification: cylindrical or tubular, varicose, saccular or cystic
- useful also in elucidating cause of focal bronchiectasis

assess distribution:
usually lower lobes
if upper lobes: suspect post TB, Cystic Fibrosis, ABPA
ir proximal bronchiectasis: ABPA
if middle lobe/lingula: M avium

complications

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29
Q

how may distribution of bronchiectasis on HRCT be suggestive of the underlying cause?

A

usually lower lobes

if upper lobes: suspect post TB, Cystic Fibrosis, ABPA
ir proximal bronchiectasis: ABPA
if middle lobe/lingula: M avium

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30
Q

characteristic auscultatory findings in pulmonary fibrosis?

A

late, fine inspiratory crepitations
velcro-like
quietens when the patient leans forwards

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31
Q

what are the causes of upper lobe pulmonary fibrosis?

A

BREAST CLAPS

Beryllium
Radiation
Extrinsic Allergic Alveolitis
Allergic bronchopulmonary aspergillosis
Silicosis
TB

Cystic fibrosis
Langerhans cell histiocytosis
Ankylosing spondylitis
Pneumoconiosis (Coal worker)
Sarcoidosis

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32
Q

what are the causes of lower lobe pulmonary fibrosis?

A

CARDI

Connective tissue disease: Systemic sclerosis
Asbestosis
Rheumatoid arthritis
Drugs: cytotoxics (e.g. MTX, azathioprine, bleomycin), phenyotin, amiodarone, hydralazine, nitrofurantoin, isoniazid, sulfasalaizine
Idiopathic pulmonary fibrosis (usual interstitial pneumonia)

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33
Q

what causes both upper and lower lobe interstitial lung disease?

A
  • neurofibromatosis, tuberous sclerosis
  • pulmonary haemorrhage syndromes
  • extrinsic allergic alveolitis
  • alveolar proteinosis (primary, secondary: silica, chronic infection, malignancy)
  • lymphangiomyomatosis
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34
Q

how would you classify interstital lung disease?

A

ATS/ERS 2001:

diffuse parenchymal lung disease of known cause:
- collagen vascular disease: RA, SLE, dermatomyositis, systemic sclerosis
- occupational/environmental: asbestosis, silicosis, extrinsic allergic alveolitis
- drug related: cytotoxic, CNS, CVS, antbiotics, rheumatic

idiopathic:
IPF
other idiopathic interstitial pneumonias

granulomatous:
sarcoidosis

others:
LAM, histiocytosis

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35
Q

what are some other idiopathic interstitial pneumonias?

A

Desquamative interstitial pneumonitis
Acute interstitial pneumonia
Lymphocytic interstitial pneumonia
Nonspecific interstitial pneumonia
Cryptogenic organising pneumonia
Respiratory bronchiolitis

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36
Q

how would you diagnose idiopathic pulmonary fibrosis?

A

clinical, radiological, pathological

clinical:
- exclusion of other causes of ILD
- insidious onset of dyspnoea, >3 months, non productive cough
- typical physical findings

radiological: HRCT

pathological

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37
Q

investigations of pulmonary fibrosis?

A

HRCT to diagnose
CXR
Lung function tests: restrictive pattern

Bronchoalveolar lavage
Lung biopsy
Bloods: ABG, to rule out other causes

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38
Q

CXR in pulmonary fibrosis?

A

diagnostic:
bilateral basal reticulonodular shadows, peripheries, which advances upwards
honeycombing in advanced cases
loss of lung volume

extent and distribution
complications

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39
Q

lung function tests in pulmonary fibrosis?

A

restrictive pattern: reduced TLC or VC with increased FEV1/FVC ratio

severity of restriction based on total lung capacity

reduced transfer factor (impaired gas exchange)

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40
Q

HRCT scan findings for pulmonary fibrosis?

A

diagnosis:
- patchy reticular abnormalities
- focal ground glass
- architectural distortion
- volume loss
- subpleural cyst
- honeycombing

extent and severity: basal, peripheral, subpleural

complications

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41
Q

indication for bronchoscopy with lavage in diagnosis of pulmonary fibrosis?

A
  • if predominantly lymphyocytes, usually responds to steroids and better prognosis (not UIP)
  • predominantly neutrophils and eosinophils means poor prognosis = UIP
  • if >20% eosinophils, to consider eosinophilic lung disease
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42
Q

management of intersitial lung disease/ pulmonary fibrosis?

A

education and counselling:
stop smoking
regular follow up and vaccinations

treat underlying cause if any

medications:
- trial of steroids: if responding, continue; if not: azathioprine or cyclophosphamide
- antifibrotics: pirfenidone

surgical: lung transplant

manage complications:
- cor pulmonale (diuretics for heart failure)
- polycythaemia (venesection if hct >55%)
- respiratory failure: oxygen therapy
- monitor for lung cancer

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43
Q

good prognostic factors for pulmonary fibrosis?

A

young age
female
short duration
ground glass appearance on CXR
minimal fibrosis on lung biopsy

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44
Q

what is the clinical course of patients with idiopathic pulmonary fibrosis?

A

gradual onset
progressive
median survival from time of diagnosis about 3 years

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45
Q

causes of death in pulmonary fibrosis?

A

cor pulmonale (right heart failure)
respiratory failure
pneumonia
lung carcinoma

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46
Q

what is hamman rich syndrome?

A

aka acute interstitial pneumonia

a rare idiopathic pulmonary disease that leads to fulminant respiratory failure (rapidly progressive, fatal variant of interstitial lung disease)

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47
Q

differential diagnoses for dullness on percussion of unilateral lower zone

A
  1. pleural thickening: old TB, prev empyema, mesothelioma, asbestosis, prev haemothorax
  2. basal consolidation
  3. lower lobe collapse
  4. raised hemidiaphragm:
    (a) phrenic nerve palsy from cancer or phrenic nerve crush for old TB treatment with supraclavicular fossa scar
    (B) hepatomegaly (right side)
  5. malignancy
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48
Q

causes of a pleural effusion

A

group into transudative and exudative causes

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49
Q

causes of a transudative pleural effusion

A
  • cardiac: congestive cardiac failure, constrictive pericarditis
  • renal: nephrotic syndrome, hypoalbuminaemia, peritoneal dialysis
  • chronic liver disease: hepatic hydrothorax
  • myxoedema (hypothyroidism)
  • atelectasis
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50
Q

causes of an exudative pleural effusion

A

malignancy: primary: bronchial or pleural, secondary: breast/pancreas/kidney/ovaries/lymphomas

infective: parapneumonic, TB
connective tissue: rheumatoid arthritis, SLE

PE
pancreatitis (left-sided)
drug induced: nitrofurantoin, bromocriptine
meig’s syndrome (ovarian fibroma, ascites and pleural effusion)
yellow nail syndrome

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51
Q

what is yellow nail syndrome?

A

triad of yellow nails/ onycholysis, pleural effusion/ bronchiectasis and lymphoedema

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52
Q

features of meig’s syndrome?

A

ovarian fibroma, ascites, pleural effusion

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53
Q

causes of haemothorax?

A

trauma
rupture of pleural adhesion containing blood vessel, carcinoma

54
Q

causes of a chylothorax?

A

trauma or surgery to the thoracic duct
carcinoma or lymphoma affecting the thoracic duct

55
Q

what is a chylothorax?

A

accumulation of lymphatic fluid within the pleural space

56
Q

what is an empyema?

A

collection of pus in the pleural space

57
Q

what is a parapneumonic effusion?

A

a pleural effusion that forms in the pleural space adjacent to a pneumonia
-> can become complicated parapneumonic effusion or empyema

58
Q

causes of empyema?

A

pneumonia
abscess
bronchiectasis
TB

59
Q

how to diagnose a pleural effusion?

A

Ultrasound

60
Q
A
61
Q

how to differentiate between an exudative and transudative effusion

A

Light’s criteria:
sensitive but not specific for exudates
- pleural fluid protein: serum protein > 0.5
- pleural fluid LDH: serum LDH > 0.6
- pleural fluid LDH >2/3 of ULN of serum LDH

if still suspecting transudate, can do SAAG (serum to pleural albumin gradient)
-> if >1.2g/dL, transudate

62
Q

ix of pleural effusion

A

evaluate for underlying cause of the effusion

sputum studies: gram stain, culture, AFB smear/culture/ TB PCR, cytology

imaging:
CXR
US
CT

Diagnostic pleural tap +/- pleural biopsy

Blood investigations

63
Q

indications for a diagnostic thoracocentesis?

A

> 10mm thick on a lateral decubitus film or USS

64
Q

turbid appearance of pleural effusion

A

parapneumonic effusion, chylothorax

65
Q

bloody looking pleural effusion: what values are significant

A

<1% insignificant
1-20%: malignancy, PE, trauma
>50% compared to peripheral Hct: haemothorax

66
Q

neutrophil predominant pleural effusion

A

parapneumonic effusion

67
Q

lymphocytes predominant pleural effusion

A

malignancy, TB, lymphoma, connective tissue disorders

68
Q

eosinophilic pleural effusion

A

blood or air in the pleural space
drugs - nitrofurantoin, bromocriptine, dantrolene
churg-strauss (eGPA)
paragonimiasis
Asbestosis

69
Q

what pleural fluid studies to send off from diagnostic thoracocentesis for pleural effusion?

A

FEME
pH
LDH
protein (Lights criteria)
glucose (<0.5 compared to serum: malignancy, TB, RA)
amylase (pancreatitis)

cultures: bacterial, TB, fungal
ADA

cytology

70
Q

when must you order cxr post diagnostic tap?

A

when you suspect complications of pneumothorax:
- air aspirated
- patient develops chest pain/ SOB
- loss of tactile fremitus over superior part of the aspirated hemithorax

71
Q

management of pleural effusion?

A

treat the underlying cause

treat symptoms: fever/ pain
SOB: therapeutic thoracocentesis

chest drain insertion: for complicated parapneumonic effusion, haemothorax

pleurodesis for malignant effusions

intrapleural fibrinolytics for loculated effusions

72
Q

features of complicated parapneumonic effusion

A

turbid appearance (if gross pus -> empyema)

criteria:
pH < 7.20
Glucose < 3.3 mmol/l (60 mg/dl)
LDH > 1000
cultures could be positive

73
Q

treatment of empyema

A

antibiotics
complete pleural fluid drainage
surgical decortication

74
Q

causes of lung collapse?

A

intraluminal: foreign body, mucous plugging from asthma/ ABPA

luminal: endobronchial tumour, TB

extrinsic compression: enlarged LNs 2’ malignancy (primary/secondary), lymphomas, TB

75
Q

what is brock’s syndrome?

A

right middle lobe (RML) atelectasis/ collapse by enlarged hilar lymphadenopathy compressing the right main bronchi

76
Q

ix of lung collapse?

A

diagnosis of lung collapse:
cxr
ABG, FBC, biochemical profile

find underlying cause:
sputum studies: AFB smear/culture, Cytology
Bronchoscopy + biopsy

Staging for cancer: CT TAP, Bone scan/ PET CT

Physiological staging: lung function tests

77
Q

management of lung collapse

A

treat underlying cause

78
Q

management of lung malignancy causing lung collapse

A

acute scenario:
ABC approach
respiratory support if required

MDT approach: discussion at tumour board (radiology, med onco, resp, thoracic surgeons)
education and counselling, stop smoking
symptomatic treatment
treatment of actual cancer: surgery/ chemo/ radiotx

79
Q

management of non small cell lung cancer?

A

refer to med onco / thoracic surgery

assessment for surgical resectability
- depends on staging: usually up to IIIA
- physiological staging: FEV1>1.5, transfer factor > 50%

chemotherapy: neoadjuvant/ adjuvant

radiotherapy: adjuvant/ palliative

palliative: radiotherapy, chemotherapy

80
Q

management of small cell lung carcinoma

A

usually aggressive

chemotherapy initiated early

prophylactic cranial irradiation against brain mets
stereotactic radiotherapy/ surgery for limited vol disease sometimes offered

81
Q

what FEV1 is required for pneumonectomy/ lobectomy

A

FEV1 >2-2.5L predicts better survival for pneumonectomy

lobectomy: usually FEV1>1.5L

82
Q

how does patient with bronchogenic carcinoma present?

A

primary tumour: cough, sob, haemoptysis, pneumonia

mediastinal: SVCO, Horner’s, pleural effusion, phrenic nerve palsy, hoarseness of voice, T1 wasting, pericardial effusion

metastases: liver, bone, brain, skin, adrenals

paraneoplastic symptoms

systemic effects: LOW, LOA, fatigue

83
Q

endocrine paraneoplastic syndromes assoc with lung cancer?

A

PTH related peptide (hypercalcaemia): SCC
SIADH: small cell
ACTH: Cushing’s (usually hypok met alkalosis)
Gynaecomastia

84
Q

neurological paraneoplastic syndromes assoc with lung cancer?

A

subacute cerebellar degeneration
peripheral neuropathies (anti-Hu antibody)
Lambert-Eaton syndrome: anti-VGCC

85
Q

paraneoplastic syndromes assoc with lung cancer affecting the skin?

A

migratory venous thrombophlebitis (trosseau’s sign)
acanthosis nigricans
dermatomyositis

86
Q

paraneoplastic syndromes assoc with lung cancer affecting MSK/joints?

A

clubbing
HPOA: Hypertrophic pulmonary osteoarthropathy

87
Q

features of SVCO?

A

plethoric facies
facial and UL oedema
conjunctival suffusion
fixed engorgement of neck veins
stridor
upper chest telangiectasia

signs of treatment: radiotherapy marks
underlying cause: lung carcinoma (esp small cell), lymphoma, mediastinal goitre

88
Q

what are the causes of a consolidation?

A

infection:
pneumonia
abscess
TB
aspergilloma, cryptococcoma, hydatid cys

neoplastic/mass: carcinoma, lymphoma

pulmonary infarction

89
Q

ix of consolidation?

A

CXR
ABG, bloods e.g. FBC CRP RP, blood c/s
sputum studies

evaluate specifically for:
infection
cancer- bronchoscopy + biopsy, CT staging, bone scan, lung function tests
infarction

90
Q

causes of an unresolved pneumonia?

A

foreign body
tumour
abscess
inappropriate antibiotics, resistant organism

bronchopulmonary sequestration: rare, congenital. non-functioning lung tissue with anomalous arterial supply with no connection to the bronchopulmonary tree

91
Q

what are the extrapulmonary manifestations of mycoplasma?

A

CNS- meningitis, encephalitis
CVS- pericarditis, myocarditis
hepatitis, GN
DIC, AIHA
Erythema multiforme, Steven-Johnson syndrome
Arthralgia, arthritis

92
Q

complications of a pneumonia?

A

local:
abscess
empyema
respiratory failure

sepsis:
septic shock
ARDS
Multi organ failure
DIC

93
Q

what are the pulmonary eosinophilic disorders?

A

defined as radiographic infiltrates with hypereosinophilia (>1.5 x 10^9 L)

  • Churg Strauss (eosinophilic granulomatosis with polyangiitis): asthma with vasculitis and hypereosinophilia
  • tropical pulmonary eosinophilia: high anti-filarial antibody
  • chronic pulmonary eosinophilia: cough, progressive sob, weight loss with diffuse peripheral pulmonary infiltrates (see CXR)
94
Q

management of pneumonia

A

depending on type:
community, hospital acquired

risk stratify: CURB-65 score

ABC approach
- may require non invasive or invasive ventilatory support in event of respiratory failure
- antibiotics

95
Q

CURB 65 score?

A

helps to risk stratify patients with pneumonia
- confusion
- urea >7mmol/L
- RR >30
- BP< 90/60
- Age 65 and above

0 to 1: low risk of death, can treat in community
2: increased risk of death. short hospitalization or supervised home treatment
3 and above; high risk of death, urgent hospitalization

96
Q

antibiotics for community acquired pneumonia?

A

generally penicillins or macrolides;
fluoroquinolones if intolerant e.g. levofloxacin

97
Q

how to assess clinical probablity of PE

A

evaluate patients for:
- SOB, tachypnoea, chest pain, haemoptysis
- absence of an alternative explanation (A)
- presence of a major risk factor (B)

if A+B= high probability
only A or B= intermediate probability
none present= low probability

98
Q

when to use d dimer in the workup of PE?

A

to use only if low or intermediate probability
high specificity= if negative, no need to do imaging
not to order if high probability-> should image immediately

99
Q

imaging options for PE

A

CTPA

VQ scan: need to have facilities available
- cxr normal
- no cardiopulmonary disorder

US DVT: to confirm if VTE present

100
Q

management of massive PE? ie BP compromised or cardiopulmonary collapse

A

thrombolysis with alteplase
thrombus fragmentation and IVC filters if expertise present and available

101
Q

management of non massive PE?

A

no thrombolysis

use of heparin before imaging in high or intermediate clinical probability
- LMWH 1st choice
- unfractionated heparin if massive PE, first dose bolus, acute reversal desired

if PE confirmed:
anticoagulation usually for 3 - 6 months

102
Q

management of PE in pregnancy

A

LMWH during pregnancy
unfractionated heparin when approaching delivery, to stop 4-6h prior delivery

oral anticoagulation commences after delivery and continued for 6 weeks or 3 months after PE whichever is longer

103
Q

management of PE in cancer patients

A

duration unknown, may be indefinite while cancer persists
- higher risk of thombosis and bleeding

if recurrent thrombosis: can aim INR 3-3.5, LMWH + anticoagulation or IVC filter

104
Q

how to diagnose COPD?

A
  • clinical: > 35 years, smoking, wheeze, SOB, cough with sputum, winter bronchitis
  • airflow obstruction: FEV1/FVC <70% and FEV1 < 80%
  • exclude differential diagnoses: asthma, cancer, bronchiectasis, ILD
105
Q

severity of airflow obstruction?

A

Mild FEV1 50-80%
Moderate 30-50%
Severe < 30%

106
Q

features suggesting asthma on lung function test

A

> 400ml improvement with bronchodilator therapy or PO pred 30mg OM for 2/52 or variation in PEFR >20%

107
Q

how do you grade the severity of dyspnea?

A

MRC scale
1- SOB on strenuous exercise
2- on hurrying or up hill
3- walks slower than contemporaries and stops for breaths
4- stops for breath after walking 100m
5- SOB on ADLs

108
Q

ix of acute COPD exacerbation?

A

fbc (anaemia, polycythaemia), inflammatory markers
ABG
blood c/s

CXR
ECG

109
Q

management of COPD?

A

non-pharm:
- education: stop smoking
- regular follow up
- vaccinations: pneumococcal, influenza
- PTOT pulmonary rehab, home adaptations
- MSW, specialist nurse for assessment of inhaler technique

pharmacological:
- Bronchodilators: LABA + LAMA +/- ICS
- theophylline
- +/- steroids
- mucolytics: acetylcysteine

manage complications of hypoxaemia, cor pulmonale, polycythaemia

surgery may be indicated

110
Q

management of acute exacerbation of COPD?

A

ABC approach
may require non invasive or invasive ventilation if respiratory failure
-> BIPAP if hypercapnoeic and pH 7.25-7.35

  • bronchodilators: salbutamol nebs
  • steroids: PO pred/ IV hydrocortisone
  • antibiotics if infective exacerbation
  • oxygen therapy
111
Q

indications for long term oxygen therapy for COPD

A

PaO2 < 55 mmHg

or

PaO2 < 60 mmHg + presence of:
- pulmonary hypertension
- polycythaemia
- cor pulmonale
- nocturnal hypoxaemia

For at least 15h/day if not 20 hours

112
Q

management of polycythaemia 2’ copd

A

if Hct > 55%, may consider venesection

113
Q

management of cor pulmonale 2’ COPD

A

diuretics

114
Q

indications for surgical management in COPD?

A

bullectomy:
- for single large bulla, FEV1 < 50%

lung volume reduction surgery: upper lobe bullous involvement
- FEV1 > 20%
- TLCO > 20%
- pO2 < 45

transplant

115
Q

when would you order alpha 1 antitrypsin levels in COPD patient

A

COPD +
- young
- family history
- no smoking history

not recommended for AAT replacement if positive for AAT deficiency, treat the COPD

116
Q

COPD + air travel?

A

higher risk of hypoxaemia -> may require supplemental O2
pressurised at 8000 ft - higher risk pneumothorax

assess with: spirometry,
if SpO2< 95% on room air, hypoxic challenge test, 50m walk test

bring inhalers in hand luggage
inform the airline

117
Q

what are the indications for a lobectomy or pneumonectomy?

A
  • malignancy: mitotic lesion
  • lung abscess
  • localised bronchiectasis or its complications
  • mycetoma, ABPA
  • TB treatment (treatment modality for pTB in the past)
  • Lung volume reduction surgery for COPD
  • Trauma
118
Q

indications for lobectomy and splenectomy?

A

TB
sarcoidosis

119
Q

contraindications to a lobectomy/ pneumonectomy in a lung cancer patient?

A

resectability:
- T4 (mediastinal structures), N3 (contralateral mediastinal or hilar or ipsilateral supraclavicular LNs or scalene) or M1
- tumour within 2cm of carina (potentially curable by radiotherapy)
- bilateral endobronchial tumour (potentially curable by radiotherapy)

physiologic staging:
- severe pulmonary hypertension
- CO2 retention
- FEV1 < 1L
- Transfer factor < 40%
- concomitant disease that would shorten life expectancy
- recent MI in the past 3 months
- borderline function with cardiopulmonary exercise testing with a maximal oxygen consumption < 15ml/kg/min

120
Q

indications for lung volume reduction surgery in COPD patients?

A
  • emphysema
  • predominantly upper lobes
  • no or mild pulmonary hypertension (PASP<45 mmhg)
  • no concomitant disabling disease
  • FEV1 > 20% (but advanced COPD so should be < 45%), DLCO> 20%

others
- severe dyspnoea despite optimal medical therapy and maximal pulmonary rehabilitation
- age < 75 years
- smoking cessation > 6 months

121
Q

likely underlying cause of a bilateral lung transplant in a young patient?

A

cystic fibrosis
alpha 1 antitrypsin deficiency
primary pulmonary hypertension
eisenmenger (Heart-lung transplant)

122
Q

likely underlying cause of a bilateral lung transplant in an older patient?

A

COPD
idiopathic pulmonary fibrosis
bronchiectasis (always bilateral)

123
Q

what are the indications for a lung transplant?

A

cardiopulmonary:
- primary pulmonary hypertension
- eisenmenger’s (heart-lung transplant)

chronic lung conditions:
- restrictive lung conditions: ILD
- obstructive: COPD, Alpha 1 antitrypsin deficiency
- suppurative: bronchiectasis, cystic fibrosis
- sarcoidosis

124
Q

what are the contraindications for lung transplant?

A

disease specific guidelines

include
- age
- comorbidities: absence of concomitant disease that shortens life expectancy
- contraindications to surgery/ GA (recent MI)
- smoking, alcoholic, poor social support

125
Q

what are the complications of a lung transplant?

A
  • graft dysfunction (reperfusion oedema in the first week)
  • airway complications: dehiscence, stensosis or bronchomalacia
  • rejection: acute/ chronic
  • Infection: CMV, aspergillus, bacterial (pseudomonas)
126
Q

what to mention in examination of patient with a lung transplant?

A
  • diagnosis
  • likely underlying cause for the lung transplant
  • complications of pulmonary hypertension, cor pulmonale, polycythaemia
  • features of treatment side effects: e.g. steroid/ cyclosporin toxicity
127
Q

acute vs chronic rejection in lung transplant patients?

A

acute:
lymphocytic inflammation
-> adjust steroid and immune suppression

chronic:
alloimmune inflammatory and non-alloimmune fibroproliferative, leads to bronchiolitis obliterans syndrome

128
Q

management of lung tranplant

A

MDT approach, requires regular follow up, transplant coordinator

3 drug maintenance:
- calcineurin inhibitor (tacrolimus, ciclosporin)
- purine synthesis antagonist (MMF, azathioprine)
- steroid

CMV and PCP prophylaxis

129
Q

what to mention in examination of patient with lobectomy/pneumonectomy

A

mention signs that may suggest underlying cause of lobectomy

130
Q

what complications to examine for in respiratory examination?

A

pulmonary hypertension
cor pulmonale
polycythaemia

any respiratory distress/ failure (cyanosis)

131
Q

what examination signs to look for in a patient with lung collapse tro malignancy

A
  • any cachexia
  • cervical lymph nodes
  • signs of SVCO
  • clubbing +/- HPOA
  • horner’s syndrome

PACES 2024 (14 decks)

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